The Mountain Echo

This week I wanted to talk about chest injuries and the problems associated with them. How do you know if you have really done yourself a serious injury? Let’s face it, they all hurt a lot, so what can be done to prevent these injuries?

What exactly are we talking about? When you fall on to your chest, or your back, your ribs stop you from damaging your internal organs i.e. your heart, lungs and to a certain extent, your liver and spleen. The classic injury is a fall on to the snow, ‘winding’ the victim and leaving significant pain on movement and inspiration thereafter. This can often happen if you land on an arm that is tucked into the chest (usually in snowboarders), which can lead to a good going rib fracture. If you’re really unlucky, to add insult to injury, your board or skis may come up behind you and collide with your head: The classic Scorpion.

Back to chest injuries, the spectrum of damage is limitless. We see these injuries most days. The majority have suffered a tear in the muscles between the ribs. These are called the intercostal muscles and help you to breathe in. Unfortunately you can’t take a rest from breathing so this hurts a lot, especially as they have a rich nerve supply. Next up is the broken rib. This is a diagnosis made on examination and not on x-ray as most people believe. The majority of rib fractures do not cause problems and are difficult to see on x-ray film, so they are not routinely done. The treatment is good painkillers, rib strapping which takes the pressure away from the injury and instructions to take deep breaths regularly. Yes, this hurts a lot but it also keeps the miniature passageways open, discouraging bacteria from growing, because if you start coughing, that injury will really hurt.

“Have I popped my lung?” is a common question we get asked. The answer is usually no. So what is a popped lung? Excuse the analogy, but imagine that your fist is a lung, now put your fist into a half blown up balloon. It is now surrounded by two layers, right? These are called the pleura. If the outer layer is speared by, for example, a fractured and displaced rib, then suddenly air can enter the space between the layers and cause your lung (the fist, if you are still following) to shrink down. This is called a pneumothorax or collapsed lung. Usually, it’s not a problem, if you are young and fit, then it will re-inflate spontaneously over days or weeks, but a large one will cause you to feel breathless, contribute to pain and may need intervention in hospital (about four percent). Smokers are at greater risk of this injury.

The liver (right) and spleen (left) are also protected by ribs. However these ribs are called floating ribs as they are only fixed at the front but not the back. A blow to the left or right hand side, typically because of an overlying arm or by landing on a rail can damage these organs. They are delicate and have a very rich blood supply. They are each surrounded by a capsule which stems the bleeding in an accident, but once this bursts, the result can be fatal. If you notice a pain in the upper left or right of the abdomen (lower chest) then think about going to see the doctor. A racing pulse is another indication.

How do you prevent this from happening? Well, short of becoming a better skier/snowboarder, avoid carrying objects such as phones/keys/wallets in pockets around the ribcage. Avalanche transceivers are often a problem due to the strapping system, try to have these in the middle of the abdomen away from organs. In short, the difference between a muscle or rib problem compared to a collapsed lung is often a feeling of shortness of breath, so get yourself looked at.

Abdominal pain or racing pulse as described above should also be investigated. If you are worried about an injury, always go and see your doctor.

Dr Alan Griffiths from the English Medical Centre outlines what can go wrong when you hurt your ankle, and explodes a couple of myths at the same time…

Ankle injuries are more common in snowboarders (16% of all boarding injuries) than in skiers (6% of all skiing injuries). This is because boarding boots allow more movement than ski boots. However, it is not true that you cannot seriously hurt your ankle in a ski boot, as the picture shows.The ankle joint is made up of the lower part of the leg bones (tibia and fibula) and the talus bone underneath. The bony prominence at the end of the fibula (the thin bone down the outside of the leg) is called the lateral malleolus. The other knobbly bit on the inside of the ankle is called the medial malleolus, and is a part of the main leg bone (tibia).

Ankle sprains are common. They occur when the foot stretches the ligaments that hold the bones together. The ligament fibres become torn, which causes pain and swelling. In severe cases it can take several weeks for the ligaments to heal. Rest, Ice, Compression and Elevation of the foot are the mainstays of treatment (R.I.C.E.). The healing process can be speeded up by immobilising the joint with strapping or a splint.

When more force is involved, the bones that the ligaments are attached to can snap. Usually it is the end of the fibula that breaks. Treatment depends on the severity of the fracture. In simple breaks all that may be required is a plaster cast. But if there is any displacement of the bone fragment, an operation to insert metalwork becomes necessary. Similarly, if more than one bone is broken an operation is a near certainty.

It is much les common for the talus to fracture, but it is still possible. Minor talar fractures are generally treated with immobilisation in a plaster cast. However, because this bone takes all of the body weight, surgery is sometimes required to stabilise the fragments with metal screws. A part of the talus called the lateral process can snap yet not show up on ordinary X-rays. This fracture is almost never encountered apart from in snowboarders. Pain over the outside of the ankle that is not responding to treatment should prompt your doctor to consider a CT scan to exclude this specific “snowboarder’s fracture”.

Finally, the Achilles tendon should not be forgotten. This tendon attaches the calf muscle to the heel. It is usually injured in a forwards fall. If a few fibres of the tendon are strained it is not too serious, and heals up quickly with the RICE treatment. But if the entire ligament snaps it will take a good three months to recover in a plaster cast. Sometimes it requires an operation to stitch it back together, but this doesn’t really shorten the recovery time. If you hurt your ankle, do not fall into the trap of thinking that “if I can walk on it, there can’t be a break”. This is not the case, but what is true is that if you do walk on a broken ankle you are more likely to displace the bone fragment and increase your chance of needing surgery (see picture).

Mythbuster: this fractured lateral malleolus occured in a ski boot, and after walking around on it for two days the patient did not think it needed an X-ray. It actually required an operation to insert a metal plate.

Sexually Transmitted Infections (STIs) are a topic of much public interest, but also taboo.  Everyone talks about them, but never from personal experience. So what dangers can unprotected sex lead to? You only need to look at the pictures and you’ll be running to buy condoms…

Many myths exist regarding STIs. Essentially, in the UK, one in nine 18-25 year olds has Chlamydia. This is an average. If you have Chlamydia, you are more likely to also have another STI. Forty percent of women and twenty percent of men with chlamydial infection are co-infected with gonorrhoea.
Let’s talk about Chlamydia first. It is a bacterium that lives within the cells of your urethra to begin with. Symptoms can include painful urination, testicular pain and penile discharge for men. Women may have painful urination, discharge, malodour, and later abdominal pain and pain during sex. Women may also notice unexpected bleeding between periods. The incubation period (period before symptoms appear) is 1-3 weeks. However, I have known men to only notice symptoms after eight weeks. Approximately 50% of infected males and 80% of infected females have no symptoms. So why is it so bad? Well, in both men and women it can travel to other areas of the reproductive system and lead to infertility. It is now the leading cause of infertility in women worldwide. This is called pelvic inflammatory disease. In addition, women with a chlamydial infection are at an increased risk of developing cervical cancer; risk is as high as 6.5 times greater compared to women without infection. It is tested for using swabs. The “umbrella” test for men is a myth. Herpes is a virus that exists in many forms. The form that is seen in genital herpes is different to that seen around the mouth (cold sores). Genital herpes is seen as painful open wounds in the skin on the penis or around the vagina. They are spread from skin to skin contact. Genital warts are spread in a similar fashion and are seen as raised often painless lumps. Again good treatments are available.

Warts, please compare with… herpes HIV (106,000 in the UK, and 7,000 new cases last year) and syphilis (ten fold increase over ten years), both exist in Val. These two illnesses can be detected by blood tests. Symptoms are varied and beyond the scope of this article. A few years ago, some life and medical insurance policies  were affected if you were tested for HIV but this is no longer  the case.

Hepatitis C, previously mainly spread through heroin use and blood transfusions is now mainly spread through unprotected sex. Depending which source you read, between 150 and 300 million people (2.5- 5%) worldwide are infected with the virus. It can have a long period of dormancy, but eventually attacks the liver leading to hepatitis. It is 100 times more contagious than HIV. It is also part of the screening test during a sexual health check.

One of the reasons for people not getting tested is embarrassment, but doctors and nurses are bound by confidentiality laws so you can be assured of privacy. Although you do have to pay for the tests, in March/April time,  Vie Val D’Is arranges free testing for many STIs. However if you have genuine concerns, get yourself checked out sooner rather than later.

The old expression “you‘re not sleeping with one person, but all their previous partners” is definitely valid. In summary, there’s a lot of rubbish spoken out there, but STIs are rife so just be careful. I actually saw a patient once who told me he’d been using two condoms at once. This is a little excessive, expensive and probably killed the mood. They are well constructed nowadays, so one will suffice, but you actually have to have one to hand for them to work, so stock up next time you’re in the pharmacy or down in Bourg.

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